Important Notice Regarding MetLife’s Long-Term Care ... · • When Medi-Cal pays your spouse’s nursing home bills, you are allowed to keep your house and furniture, a living

Important Notice Regarding MetLife’s Long-Term Care Inforce Rate Increase History

(Please note the information below replaces the Rate Increase History section of the Long Term Care Insurance Personal Worksheet on the application.)

MetLife has ceased marketing its individual and group Long-Term Care products. Please be advised that with respect to premium rates for existing policyholders, MetLife has raised, or expects to raise, rates on the LTC policy series noted below. Policy Type Individual Policy

Series* Years Available Years Increase

Began Percentage of Increase

Individual LTC 1LTC-97, 2LTC-97 1997 – 2001 2009 2013 2016

0-18% 0-58% 0-102%****

Individual LTC LTC-VAL, LTC-IDEAL, LTC-PREM, LTC-FAC

2002-2006 2009 2013 2016

0-42% 0-102% 0-126%****

Individual LTC LTC2-VAL, LTC2-IDEAL, LTC2-PREM, LTC2-FAC

2005-2011 2013 2016

0-88% 0-88%****

Individual LTC LTC2007 2008-2011 2013 2016

0-58% 0-58%****

Individual LTC LTC-TIAA-02 1991-2001 2012 2015

0-41% 0-73%****

Individual LTC LTC-TIAA-03 1992-2003 2012 2015

0-41% 0-73%****

Individual LTC LTC-TCL-04 2000-2004 2012 2015

0-41% 0-73%****

Group LTC G.LTC197 1998 – 2003** 2012 0-45% Group LTC GPNP99-LTC 2000 – 2010*** 2012 0- 45% *Please note some policy forms may be followed by a state abbreviation or a state abbreviation and the letters “ML.” **While MetLife ceased offering the group policy to group policyholders in the year noted, certificates under the group policy continued to be issued on applications taken through December 31, 2012. ***While MetLife ceased offering the group policy to group policyholders in the year noted, certificates under the group policy continued to be issued on applications taken through December 31, 2012. ****Please note that the percentage of the increase will vary by state, and state filings are in process. Final amounts are subject to any applicable regulatory approvals.

Long-Term Care InsuranceIndividual Application & Important Forms

Long-Term Care Insurance (LTCI)

Metropolitan Life Insurance CompanyNew York, NY 10166

For use in the state of

CALIFORNIA

Metropolitan Life Insurance Company, New York, NY 10166

IMPORTANT INSTRUCTIONS FOR AGENTS

• Complete all application pages. Tear out all pages labeled “MAIL THIS PAGE TO METLIFE” and returnthem to MetLife. Application pages labeled “LEAVE THIS PAGE WITH APPLICANT” stay with applicant.

• All applicants between the ages of 56 - 74 will require a phone health interview. Other applicants may becontacted at the underwriter’s discretion. The call is initiated by a Registered Nurse representing MetLife.The interview lasts approximately 20 -30 minutes, depending on health history. To save time during theinterview, please ask your client to have the following available:

• Current medication bottles • Names of physicians • Dates of any surgeries or hospitalizations

• Please indicate under Part D: DETAILS, the best time to reach your client.All applicants between the ages of 75-84 will require a face-to-face interview and assessment. Medicalrecords from the primary physician are required on all applicants age 61 and older or at the underwriter’sdiscretion for age 60 and younger.

• If you are collecting premium payment at time of application:

You may not collect more than 1 months’ premium payment

• The Beneficiary Designation Form for the Return of Premium Rider should only be completed if theApplicant is selecting the Return of Premium Rider and chooses to designate a beneficiary other thantheir estate.

• Please have applicant review the form titled CA Authorization To Release Information and returnif necessary.

A Long-Term Care Insurance policy may pay most of the costs for your care in a nursing home. Many policies also pay for care at home or other community settings.Since policies can vary in coverage, you should read this policy thoroughly and makesure you understand what it covers before you purchase.

• You should not purchase this policy unless you can afford to pay the premiumsevery year. Remember that the company may increase premiums in the future.

• The personal worksheet includes questions designed to help you and thecompany determine whether this policy is suitable for your needs.

Medicare is not designed to pay for long-term care.

Medi-Cal will generally pay for long-term care services if you have very little income and few assets. If you are now eligible for Medi-Cal, you should not purchase this policy.

• Many people become eligible for Medi-Cal after they have exhausted theirown financial resources paying for long-term care services.

• When Medi-Cal pays your spouse’s nursing home bills, you are allowedto keep your house and furniture, a living allowance, and some of yourjoint assets.

• Your choice of long-term care services may be limited if you are receivingMedi-Cal. To learn more about Medi-Cal, contact your local or stateMedi-Cal agency.

Make sure the insurance company or agent gives you a copy of a book called the “Taking Care of Tomorrow A Consumer’s Guide to Long Term Care.” Read it care-fully. If you have decided to apply for Long-Term Care Insurance, you have the rightto return the policy within 30 days and receive a full refund of any premium you hadpaid if you are dissatisfied for any reason or choose not to purchase the policy.

Free counseling and additional information about Long-Term Care Insurance is available through California’s state insurance counseling program. Contact your CA Insurance Department or Department on Aging for more information about the senior health insurance counseling program in your state.

THINGS YOU SHOULD KNOW BEFORE YOU BUY LONG-TERM CARE INSURANCE

Long-Term Care Insurance

Medicare

Medi-Cal

Shopper’s Guide

Counseling

LEAVE THIS PAGE WITH APPLICANT

i CA

THIS PAGE IS INTENTIONALLY LEFT BLANK.

LONG-TERM CARE INSURANCE PERSONAL WORKSHEET

PW2004NNCR-CA iii

MAIL THIS PAGE TO METLIFE

APPLICANT 1 NAME:

People buy Long-Term Care Insurance for many reasons. Some don’t want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don’t wanttheir family to have to pay for care or don’t want to go on Medi-Cal. But long-term care insurance may be expensive, and may not be right for everyone.By state law, the insurance company must fill out part of the information on this worksheet and ask you to fill outthe rest to help you and the company decide if you should buy this policy.

PREMIUM INFORMATION

Policy Form Number(s)

The premium for the coverage you are considering will be: $ per month, or $ per year.

A rate guide is available that compares the policies sold by different insurers, the benefits provided in those policies,and sample premiums. The rate guide also provides a history of the rate increases, if any, for the policies issued by different insurers in each state in which they do business, since January 1, 1990. You can obtain a copy of this rate guide by calling the Department of Insurance’s consumer toll-free telephone number (1-800-927-HELP), by calling theHealth Insurance Counseling and Advocacy Program’s (HICAP) toll-free telephone number (1-800-434-0222), or byaccessing the Department of Insurance’s internet web site (www.insurance.ca.gov).

TYPE OF POLICY: Guaranteed Renewable

THE COMPANY’S RIGHT TO INCREASE PREMIUMS: The company has a right to increase premiums on this policyform in the future, provided it raises rates for all policies in the same class in this state.

RATE INCREASE HISTORY: The company has sold long-term care insurance since 1986, and has sold this policy since 2005. MetLife has never increased its rates for long-term care insurance offered by agents to individuals,for long-term care insurance sponsored by employer groups, or for long-term care insurance endorsed by associa-tions. MetLife has only increased its rates for long-term care insurance covering residents of two Continuing Care Retirement Communities (CCRCs). Each increase shown below affected less than 0.6% of MetLife's total long-term care insurance business.

Group Years Year(s) of PercentageCCRC Policy Form Available Increase of IncreaseCommunity A #G.9708 1986-97 1995-97 10% each yearCommunity B #G.9873 1989-98 1999 9%-38%

QUESTIONS RELATED TO YOUR INCOMEHow will you pay each year's premium? (check one)

From my Income From my Savings/Investments Family members

Have you considered whether you could afford to keep this policy if the premiums went up, for example, by 20%?

What is your annual income? (check one) Under $10,000 $10,000 - $19,999 $20,000 - $29,999

$30,000 - $49,999 Over $50,000How do you expect your income to change over the next ten years? (check one)

No change Increase DecreaseIf you will be paying premiums with money received only from your own income, a rule of thumb is that you may

not be able to afford this policy if the premiums will be more than 7% of your income.Have you considered how you will pay for the difference between future costs and your daily benefit amount?


The national average annual cost of nursing facility care in 2005 was $64,240, but this figure varies across the country. In ten years the national average annual cost would be about $104,640 if costs increase 5% annually.1

1 “MetLife Mature Market Institute. “The MetLife Market Survey of Nursing Home and Home Care Costs,” September 2005.

LONG-TERM CARE INSURANCE PERSONAL WORKSHEET (CONTINUED)

PW2004NNCR-CA iv

SIGN & MAIL THIS PAGE TO METLIFE

QUESTIONS RELATED TO YOUR INCOME (CONTINUED)

What elimination period are you considering?

Number of days Approximate cost $ for that period of care.

How are you planning to pay for your care during the elimination period? (check one)


QUESTIONS RELATED TO YOUR SAVING/INVESTMENTS

Not counting your home, about how much are all of your assets worth (your savings and investments)? (check one)Under $20,000 $20,000 - $29,999 $30,000 - $49,999 Over $50,000

How do you expect your assets to change over the next ten years? (check one)No change Increase Decrease

If you are buying this policy to protect your assets and your assets are less than $30,000,you may wish to consider other options for financing the cost of long-term care services.

APPLICANT 1

SIGN

SIGN

SIGN

DISCLOSURE STATEMENTAPPLICANT 1 If the applicant elects not to disclose any information in the Personal Worksheet, he/she is still

required to sign and date below. (check one):The answers to the questions above describe my financial situation orI choose not to disclose this information(this box must be checked) I acknowledge that the carrier and/or its agent (below) has reviewed this form withme including the premium, premium rate increase history and potential for premium increases in the future. I understand the above disclosures. I understand that the rates for this policy may increase in the future.

Date:Signature of Applicant 1

AGENT

I explained to the applicant the importance of completing this information.

Date:Signature of Authorized Agent

Agent’s Printed Name:

In order for us to process your application, please return this signed statement to MetLife, along with your application.

IF APPLICABLE

My agent has advised me that this policy does not appear to be suitable for me. However, I still want the company to consider my application.


The company may contact you to verify your answers.

LONG-TERM CARE INSURANCE PERSONAL WORKSHEET


APPLICANT 2 NAME:

People buy Long-Term Care Insurance for many reasons. Some don’t want to use their own assets to pay for long-term care. Some buy insurance to make sure they can choose the type of care they get. Others don’t wanttheir family to have to pay for care or don’t want to go on Medi-Cal. But long-term care insurance may be expensive, and may not be right for everyone.By state law, the insurance company must fill out part of the information on this worksheet and ask you to fill outthe rest to help you and the company decide if you should buy this policy.

PREMIUM INFORMATION

Policy Form Number(s)

The premium for the coverage you are considering will be: $ per month, or $ per year.

A rate guide is available that compares the policies sold by different insurers, the benefits provided in those policies,and sample premiums. The rate guide also provides a history of the rate increases, if any, for the policies issued by different insurers in each state in which they do business, since January 1, 1990. You can obtain a copy of this rate guide by calling the Department of Insurance’s consumer toll-free telephone number (1-800-927-HELP), by calling theHealth Insurance Counseling and Advocacy Program’s (HICAP) toll-free telephone number (1-800-434-0222), or byaccessing the Department of Insurance’s internet web site (www.insurance.ca.gov).

TYPE OF POLICY: Guaranteed Renewable

THE COMPANY’S RIGHT TO INCREASE PREMIUMS: The company has a right to increase premiums on this policyform in the future, provided it raises rates for all policies in the same class in this state.

RATE INCREASE HISTORY: The company has sold long-term care insurance since 1986, and has sold this policy since 2005. MetLife has never increased its rates for long-term care insurance offered by agents to individuals,for long-term care insurance sponsored by employer groups, or for long-term care insurance endorsed by associa-tions. MetLife has only increased its rates for long-term care insurance covering residents of two Continuing Care Retirement Communities (CCRCs). Each increase shown below affected less than 0.6% of MetLife's total long-term care insurance business.

Group Years Year(s) of PercentageCCRC Policy Form Available Increase of IncreaseCommunity A #G.9708 1986-97 1995-97 10% each yearCommunity B #G.9873 1989-98 1999 9%-38%

QUESTIONS RELATED TO YOUR INCOMEHow will you pay each year's premium? (check one)


Have you considered whether you could afford to keep this policy if the premiums went up, for example, by 20%?

What is your annual income? (check one) Under $10,000 $10,000 - $19,999 $20,000 - $29,999

$30,000 - $49,999 Over $50,000How do you expect your income to change over the next ten years? (check one)

No change Increase DecreaseIf you will be paying premiums with money received only from your own income, a rule of thumb is that you may

not be able to afford this policy if the premiums will be more than 7% of your income.Have you considered how you will pay for the difference between future costs and your daily benefit amount?


The national average annual cost of nursing facility care in 2005 was $64,240, but this figure varies across the country. In ten years the national average annual cost would be about $104,640 if costs increase 5% annually.1

1 “MetLife Mature Market Institute. “The MetLife Market Survey of Nursing Home and Home Care Costs,” September 2005.

PW2004NNCR-CA v

LONG-TERM CARE INSURANCE PERSONAL WORKSHEET (CONTINUED)

PW2004NNCR-CA vi


QUESTIONS RELATED TO YOUR INCOME (CONTINUED)

What elimination period are you considering?

Number of days Approximate cost $ for that period of care.

How are you planning to pay for your care during the elimination period? (check one)


QUESTIONS RELATED TO YOUR SAVING/INVESTMENTS

Not counting your home, about how much are all of your assets worth (your savings and investments)? (check one)Under $20,000 $20,000 - $29,999 $30,000 - $49,999 Over $50,000

How do you expect your assets to change over the next ten years? (check one)No change Increase Decrease

If you are buying this policy to protect your assets and your assets are less than $30,000,you may wish to consider other options for financing the cost of long-term care services.

APPLICANT 2

SIGN

SIGN

SIGN

DISCLOSURE STATEMENTAPPLICANT 2 If the applicant elects not to disclose any information in the Personal Worksheet, he/she is still

required to sign and date below. (check one):The answers to the questions above describe my financial situation orI choose not to disclose this information(this box must be checked) I acknowledge that the carrier and/or its agent (below) has reviewed this form withme including the premium, premium rate increase history and potential for premium increases in the future. I understand the above disclosures. I understand that the rates for this policy may increase in the future.


AGENT

I explained to the applicant the importance of completing this information.

Date:Signature of Authorized Agent

Agent’s Printed Name:

In order for us to process your application, please return this signed statement to MetLife, along with your application.

IF APPLICABLE

My agent has advised me that this policy does not appear to be suitable for me. However, I still want the company to consider my application.


The company may contact you to verify your answers.

AUTHORIZATION TO PROCEED PROCESSING APPLICATION

vii ATP07-VIP2


APPLICANT 1

Applicant Signature Date

If the applicant elects not to complete the Long-Term Care Insurance Personal Worksheet, this form must becompleted and submitted with the application and the signed Long-Term Care Insurance Personal Worksheetin order to process the application.

TO: Long-Term Care Division, Metropolitan Life Insurance Company

Re: Financial Suitability of the purchase of Long-Term Care InsuranceI am applying for long-term care insurance. My Agent/Producer has explained to me that my financial situation is animportant consideration as to whether or not long-term care insurance is an appropriate purchase for me.

My Agent/Producer has also explained the importance of completing the Long-Term Care Insurance PersonalWorksheet. This information can help me determine whether I should purchase long-term care insurance and canafford to pay the required premium.

I hereby confirm that I choose not to complete the financial information on the Long-Term Care Insurance PersonalWorksheet. Nevertheless, I request that you continue to process my application for long-term care insurance coverage.

SIGN

APPLICANT 2

Applicant Signature Date

If the applicant elects not to complete the Long-Term Care Insurance Personal Worksheet, this form must becompleted and submitted with the application and the signed Long-Term Care Insurance Personal Worksheetin order to process the application.

TO: Long-Term Care Division, Metropolitan Life Insurance Company

Re: Financial Suitability of the purchase of Long-Term Care InsuranceI am applying for long-term care insurance. My Agent/Producer has explained to me that my financial situation is animportant consideration as to whether or not long-term care insurance is an appropriate purchase for me.

My Agent/Producer has also explained the importance of completing the Long-Term Care Insurance PersonalWorksheet. This information can help me determine whether I should purchase long-term care insurance and canafford to pay the required premium.

I hereby confirm that I choose not to complete the financial information on the Long-Term Care Insurance PersonalWorksheet. Nevertheless, I request that you continue to process my application for long-term care insurance coverage.

SIGN

viii

Application for Individual Long-Term Care Insurance

TABLE OF CONTENTS

Metropolitan Life Insurance Company New York, NY 10166

PART A Person(s) Applying for Coverage ....................................................................1-2

PART B Insurability Questions......................................................................................3-4

PART C Coverage Selections..........................................................................................5-6

PART D Health Questions ............................................................................................7-11

PART E How You Want to Pay Premiums ................................................................12-13

PART F Replacement Questions ....................................................................................15

PART G Agreement and Acknowledgement..............................................................17-19

AR Agent’s Report ..............................................................................................20-21

CR Conditional ReceiptApplicant 1 ......................................................................................................23-26Applicant 2 ......................................................................................................27-30

AUTH Authorization to Release Information to MetLifeApplicants 1 & 2 ..............................................................................................31-35

California Authorization to Release InformationApplicants 1 & 2 ..............................................................................................37-43

CPN Consumer Privacy NoticeApplicant 1 ......................................................................................................45-46Applicant 2 ......................................................................................................47-48

RPN Replacement NoticeApplicant 1 ............................................................................................................49Applicant 2 ............................................................................................................51

BDF Beneficiary Designation FormApplicant 1 ......................................................................................................53-54Applicant 2 ......................................................................................................55-56

RCL Replacement ChecklistApplicant 1 ......................................................................................................57-58Applicant 2 ......................................................................................................59-60

CA AUTH

AGENT

All pages labeled “MAIL THIS PAGE TO METLIFE”, the Authorizationand, if a replacement policy, the Replacement Notice must be submitted to:Metropolitan Life Insurance Company Individual Long-Term Care

Payment Enclosed: $________________


PART A PERSON(S) APPLYING FOR COVERAGE

APPLICANT 1 APPLICANT 2

A complete copy of this application consists of pages 1-19.

Please complete ALL information for EACH applicant below.


THE POLICY IS AN APPROVED LONG-TERM CARE INSURANCE CONTRACT UNDER CALIFORNIALAW AND REGULATIONS. HOWEVER, THE BENEFITS PAYABLE BY THE POLICY WILL NOT QUALIFY FOR MEDI-CAL ASSET PROTECTION UNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE. FOR INFORMATION ABOUT POLICIES AND CERTIFICATES QUALIFYINGUNDER THE CALIFORNIA PARTNERSHIP FOR LONG-TERM CARE, CALL THE HEALTH INSURANCE COUNSELING AND ADVOCACY PROGRAM AT THE TOLL-FREE NUMBER, 1 (800) 434-0222.

The Contract for Long-Term Care Insurance is intended to be a federally qualified Long-Term Care Insurance contract and may qualify you for federal and state tax benefits.


Mr. Mrs. Ms. Dr. (check one)

1.First Name Middle Initial

2.Last Name

3.Address Apt. #

4.City State Zip

5.Home Phone

6.Work Phone

7. Gender: Male Female

Mr. Mrs. Ms. Dr. (check one)

1.First Name Middle Initial

2.Last Name

3.Address Apt. #

4.City State Zip

5.Home Phone

6.Work Phone

7. Gender: Male Female

LTC3-APP-CA 1 0310

PART A PERSON(S) APPLYING FOR COVERAGE (CONTINUED)

LTC3-APP-CA 2



*“Domestic Partner” means each of two people: who have registered or filed as Domestic Partners or members of a civil unionwith a government agency or office where such registration is available; or who meet the following requirements: each personis 18 years of age or older; neither person is married; they share the same residence; they are not related by blood in a mannerthat would bar their marriage in the jurisdiction in which they reside; and they have an exclusive mutual commitment to sharethe responsibility to each other’s welfare and financial obligations and such commitment is expected to last indefinitely.

8. Date of Birth: (MM/DD/YYYY)

9. Social Security #:

10. Status: Single

Married

Domestic Partner*

(Please check “Single”

if you are widowed

or divorced.)

11. Is your Spouse or DomesticPartner* applying for coverage? Yes No

IF “YES” your Spouse’s or Domestic Partner’s*:

12. Name: ______________________________________

Social Security #: ____________________________

13. Is any other member of yourhousehold applying for coverage? Yes No

IF “YES”

14. Name:______________________________________

Social Security #: ____________________________

15. This is a request for: Initial Coverage

Increase in Coverage

Re-apply

8. Date of Birth: (MM/DD/YYYY)

9. Social Security #:

10. Status: Single

Married

Domestic Partner*

(Please check “Single”

if you are widowed

or divorced.)

11. Is your Spouse or DomesticPartner* applying for coverage? Yes No

IF “YES” your Spouse’s or Domestic Partner’s*:

12. Name: ______________________________________

Social Security #: ____________________________

13. Is any other member of yourhousehold applying for coverage? Yes No

IF “YES”

14. Name:______________________________________

Social Security #: ____________________________

15. This is a request for: Initial Coverage

Increase in Coverage

Re-apply

PART B INSURABILITY QUESTIONS


LTC3-APP-CA 3


1. Have you had, do you currently have, have you ever been medicallydiagnosed as having or have you been treated for: Yes No Yes No

a. Alzheimer’s disease?

b. Dementia?

c. Frequent or persistent forgetfulness that is progressive or for whichyou take medication?

d. Mental retardation?

e. Parkinson’s disease or syndrome?

f. Multiple sclerosis?

g. Amyotrophic lateral sclerosis (Lou Gehrig’s disease)?

h. Muscular dystrophy?

i. Stroke or any other type of cerebral vascular accident (CVA)within the last 5 years?

j. Multiple strokes?

k. Stroke with residual impairment?

l. Transient ischemic attack (TIA) within the last 5 years?

m. Multiple transient ischemic attacks (TIA)?

n. Acquired Immune Deficiency Syndrome (AIDS)?

o. AIDS related complex (ARC)?

p. Immune deficiency disorder (except HIV infection)?

q. Cancer that has spread to another area of your body, including lymph nodes?

r. Cancer treated in past 24 months (except basal cell or squamous cellcancer of the skin or early stage breast or prostate cancer)?

s. Cirrhosis of the liver?

t. Any chronic respiratory disease, in combination with smoking?

u. Congestive heart failure for which you are currently being treated(including treatment by medication)?

Please answer these questions BEFORE you continue with other parts of this Application.

PART B INSURABILITY QUESTIONS (CONTINUED)


Yes No Yes No

v. Diabetes with Physician diagnosed complication (except Retinopathy)?

w. Schizophrenia?

x. Any mental or nervous disorder for which you have been hospitalizedin the past 2 years?

y. Any mental or nervous disorder for which you have had multiplehospitalizations?

2. Have you had, or do you plan to have, any organ transplant(except corneal transplant)?

3. Do you require human assistance or supervision for any of the followingactivities:

a. bathing?

b. dressing?

c. eating?

d. getting in or out of bed or a chair?

e. walking?

f. use of toilet?

g. bowel or bladder control?.

4. Do you currently use a

a. wheelchair?

b. motorized scooter?

c. walker?

d. quad cane?

e. dialysis?

f. oxygen treatment for respiratory disease or heart disease?

5. Are you currently residing in a Nursing Facility or Residential Care Facilityor Residential Care Facility for the elderly?

6. Are you currently receiving home health care services or attendingadult day health care?

If you answered “YES” to any part of PART B, questions 1-6, PLEASE DO NOT CONTINUE.

We regret that we cannot offer you Long-Term Care Insurance coverage.

If you answered “NO” to all of PART B, questions 1-6 please CONTINUE...


LTC3-APP-CA 4

PART C COVERAGE SELECTIONS YOU ARE APPLYING FOR


LTC3-APP-CA 5

APPLICANT 1 APPLICANT 21. Select Your Plan of Coverage:

Value

Ideal

Nursing Facility/Residential Care Facility-Only

2. Select Your Maximum Nursing Home Daily BenefitAmount (“DBA”):

DBA: $ ($90 to $400 per day, in $10 increments)

Note: $100 minimum DBA required if selecting the Ideal policy.

3. Select Your Benefit Period Multiplier:(Your Total Lifetime Benefit = Benefit Period X DBA)

730 (2-year) 1,095 (3-year) 1,460 (4-year)

1,825 (5-year) 2,555 (7-year)

4. Select the percentage of DBA to be paid forPrimary Services:Do not select any of the following if a Nursing

Facility/Residential Care Facility-Only Policy is chosen

a. For Value, select your Home Care and Residential

Care Facility paid at: 100% 75%

b. For Ideal, select your Home Care paid at:

100% 75% 50%

($100 minimum DBA required)

(continued)

1. Select Your Plan of Coverage:

Value

Ideal

Nursing Facility/Residential Care Facility-Only

2. Select Your Maximum Nursing Home Daily BenefitAmount (“DBA”):

DBA: $ ($90 to $400 per day, in $10 increments)

Note: $100 minimum DBA required if selecting the Ideal policy.

3. Select Your Benefit Period Multiplier:(Your Total Lifetime Benefit = Benefit Period X DBA)

730 (2-year) 1,095 (3-year) 1,460 (4-year)

1,825 (5-year) 2,555 (7-year)

4. Select the percentage of DBA to be paid forPrimary Services:Do not select any of the following if a Nursing

Facility/Residential Care Facility-Only Policy is chosen

a. For Value, select your Home Care and Residential

Care Facility paid at: 100% 75%

b. For Ideal, select your Home Care paid at:

100% 75% 50%

($100 minimum DBA required)

(continued)


LTC3-APP-CA 6

PART C COVERAGE SELECTIONS YOU ARE APPLYING FOR (CONTINUED)


5. Select an Elimination Period:

20 Days 45 Days 100 Days

6. Select Optional Riders:

Indemnity Rider(Available with Value policy only)

Shared Care RiderSpouse/Domestic Partner must have identical coverage (Not available with Restoration ofBenefits Rider)

Paid-Up Survivorship Rider

Calendar Day Rider (Only available with Value & Ideal policies; Notavailable with Home Care EP Waiver)

Home Care EP Waiver(Only available with Value & Ideal policies; Notavailable with Calendar Day Rider)

Restoration of Benefits Rider(Not available with Shared Care Rider)

Return of Premium Rider To designate a beneficiary under this rider, you must complete the Beneficiary Designation Form required by MetLife.

7. Benefit Increase Options (choose one):

5% Automatic Compound Inflation Protection Rider

5% Automatic Simple Benefit Increase Rider

Future Purchase Rider*

No Inflation Protection Rider

* Not available if an Accelerated Premium Payment Rider

is selected.

8. Nonforfeiture Coverage Rider:

I Select Nonforfeiture Coverage Rider

Yes No

5. Select an Elimination Period:

20 Days 45 Days 100 Days

6. Select Optional Riders:

Indemnity Rider(Available with Value policy only)

Shared Care RiderSpouse/Domestic Partner must have identical coverage (Not available with Restoration ofBenefits Rider)

Paid-Up Survivorship Rider

Calendar Day Rider (Only available with Value & Ideal policies; Notavailable with Home Care EP Waiver)

Home Care EP Waiver(Only available with Value & Ideal policies; Notavailable with Calendar Day Rider)

Restoration of Benefits Rider(Not available with Shared Care Rider)

Return of Premium Rider To designate a beneficiary under this rider, you must complete the Beneficiary Designation Form required by MetLife.

7. Benefit Increase Options (choose one):

5% Automatic Compound Inflation Protection Rider

5% Automatic Simple Benefit Increase Rider

Future Purchase Rider*

No Inflation Protection Rider

* Not available if an Accelerated Premium Payment Rider

is selected.

8. Nonforfeiture Coverage Rider:

I Select Nonforfeiture Coverage Rider

Yes No


LTC3-APP-CA 7

PART D HEALTH QUESTIONS


PRIMARY PHYSICIAN who has most of your medical records:

Name: ______________________________________

Telephone: (________)__________________________

Address: _____________________________________

City: _______________________________________

State:___________________ Zip:_______________

PRIMARY PHYSICIAN who has most of your medical records:

Name: ______________________________________

Telephone: (________)__________________________

Address: _____________________________________

City: _______________________________________

State:___________________ Zip:_______________

APPLICANT 1 APPLICANT 21. Have you had, do you currently have, have you been medically

diagnosed as having or have you been treated for: Yes No Yes No

a. Cancer (except basal cell cancer or squamous cell cancer of the skin)?

b. Heart disease?

c. Congestive heart failure?

d. Arrhythmia?

e. Angina?

f. Heart attack?

g. Heart surgery?

h. Angioplasty?

i. Hypertension?

j. Stroke or any other type of Cerebral Vascular Accident (CVA)?

k. Transient Ischemic Attack (TIA)?

l. Chronic lung disease?

m. Chronic liver disease?

n. Chronic kidney disease?

o. Diabetes – insulin or non-insulin dependent?

p. Chronic neurological disease?

q. Seizure disorder?

r. Condition of the spine or peripheral nerves?

s. Psychiatric disorder?

t. Depression?

PART D HEALTH QUESTIONS (CONTINUED)

LTC3-APP-CA 8



Yes No Yes No

u. Arthritis?

v. Muscle disorder (e.g., fibromyalgia)?

w. Immune system disorder (except HIV infection)?

x. Connective tissue disorder (e.g., Scleroderma)?

y. Lupus erythematosus?

z. Amputation?

aa. Osteoporosis?

bb. Joint replacement?

cc. Fractured hip?

dd. More than one fractured bone in the last 2 years?

ee. Any falls in the last 2 years?

ff. Paralysis?

gg. Weakness of extremities?

hh. Numbness of extremities?

ii. Tremors?

jj. Imbalance?

kk. Gait disturbance?

ll. Dizziness?

mm. Memory loss?

2. Do you currently use any medical equipment(e.g., cane, brace, crutches, or stair lift)?

3. Do you require assistance in activities such as

a. shopping?

b. managing finances?

c. meal preparation?

d. transportation?

e. laundry?

f. taking your medications?


LTC3-APP-CA 9



Yes No Yes No

4. Are you currently receiving any

a. disability income?

b. worker’s compensation?

c. social security disability income?

d. federal or state disability payments?

5. Have you ever had an application for

Life Insurance:

a. declined?

b. postponed?

c. rated less than standard?

Health Insurance:

d. declined?

e. postponed?

f. rated less than standard?

Long-Term Care Insurance:

g. declined?

h. postponed?

i. rated less than standard?

6. Have you ever resided in or been advised to enter a

a. nursing facility?

b. residential care facility?

c. residential care facility for the elderly?

d. retirement community?

7. Have you ever received home health care services or attended adult dayhealth care?

8. In the last 2 years, have you been hospitalized?

9. Have you had any past surgeries, or do you plan to have surgery?

10. Have you been advised to seek medical attention for any symptoms,testing, surgery or treatment?


LTC3-APP-CA 10



Medication: __________________________________

Prescribing Physician:__________________________

Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


(continued)

Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


Medication: __________________________________


(continued)

APPLICANT 1 APPLICANT 2Yes No Yes No

11. Have you taken any prescription medications during the past 12 months?

IF “YES” to Part D question 11, please list medications below.Please use additional paper, if necessary.



LTC3-APP-CA 11


17. Do you:

a. exercise? Yes No

IF “YES” please describe: ___________________

________________________________________

________________________________________

b. drive a motor vehicle? Yes No

IF “YES” how many miles per week? ________

c. work outside the home? Yes No


________________________________________

________________________________________

d. do volunteer work? Yes No


________________________________________

________________________________________

e. have hobbies? Yes No


________________________________________

________________________________________

(continued)

17. Do you:

a. exercise? Yes No


________________________________________

________________________________________

b. drive a motor vehicle? Yes No

IF “YES” how many miles per week? ________

c. work outside the home? Yes No


________________________________________

________________________________________

d. do volunteer work? Yes No


________________________________________

________________________________________

e. have hobbies? Yes No


________________________________________

________________________________________

(continued)

APPLICANT 1 APPLICANT 2Yes No Yes No

12. Have you used tobacco products within the last 2 years?

IF “YES” date of last use

13. Do you currently use alcoholic beverages?

IF “YES” How often?

How much?

14. Have you ever been treated, hospitalized or counseledfor the use of alcohol or controlled substances?

IF “YES” date of treatment:

15. What is your height? (in inches)

16. What is your weight? (in pounds)

PART E HOW YOU WANT TO PAY PREMIUMS

LTC3-APP-CA 12


APPLICANT 1 APPLICANT 21. Choose only ONE Premium Payment Option:

Standard Mode

ACCELERATED PAYMENT RIDERS:Double Pay First Year Rider

Reduced Pay at Age 65 Rider

Paid-Up Premiums Rider

Ten Year Premium Payment Rider

2. Choose any ONE of the payment methods andmodes below.Please note that paying insurance premiums more oftenthan annually will cost more than paying them once ayear. (e.g.: If premium is $1,000 Annually – selectingQuarterly would increase your Annual premium by $60.)

a. Direct Bill (Select premium mode):

Annually

Semi-Annually (2% more than Annually)

Quarterly (6% more than Annually)

Monthly Automatic Checking Account Deduction(complete Part E, #3) (8% more than Annually)

b. Third-party payer (if applicable):Select premium mode:

Annually



FOR A OR B MAIL BILL TO:

Full Name: _______________________________

Address: _________________________________

Apt. # ______ City: ________________________

State: ___________ Zip: ____________________

Telephone: (______) ________________________

(continued)

1. Choose only ONE Premium Payment Option:

Standard Mode

ACCELERATED PAYMENT RIDERS:Double Pay First Year Rider

Reduced Pay at Age 65 Rider

Paid-Up Premiums Rider

Ten Year Premium Payment Rider

2. Choose any ONE of the payment methods andmodes below.Please note that paying insurance premiums more oftenthan annually will cost more than paying them once ayear. (e.g.: If premium is $1,000 Annually – selectingQuarterly would increase your Annual premium by $60.)

a. Direct Bill (Select premium mode):

Annually



Monthly Automatic Checking Account Deduction(complete Part E, #3) (8% more than Annually)

b. Third-party payer (if applicable):Select premium mode:

Annually



FOR A OR B MAIL BILL TO:

Full Name: _______________________________

Address: _________________________________

Apt. # ______ City: ________________________

State: ___________ Zip: ____________________

Telephone: (______) ________________________

(continued)

PART E HOW YOU WANT TO PAY PREMIUMS (CONTINUED)

LTC3-APP-CA 13



! !

SIGN SIGN

ELECTRONIC PAYMENT AGREEMENT AUTHORIZATION

3. Automatic Checking Account Deduction(Monthly):

Your monthly premium will be deductedautomatically from the bank or credit unionchecking account you request.

If you are submitting cash with yourapplication you must enclose onemonths’ premium. Enclose a voidedblank check for the account you wish to use.

If using a credit union account, please providecredit union phone number.

Phone #: (______) _______________________

I authorize: (1) MetLife to initiate monthly deductions from my checking account, by electronic or other means, as payment for the coverage level selected; and (2) the financial institution on which my enclosed sample check(marked VOID) is drawn to: (a) accept the deductions initiated by MetLife; and (b) giveMetLife my most recent address upon MetLife’srequest. Deductions will continue until MetLife has had a reasonable opportunity to act upon mywritten request to end this service. I authorizedeductions to be taken on the day of the month, or the next business day. If no day is selected, deductions will be taken on the first business day of the month.

______________________________Signature of Account Holder for Monthly Automatic Deductions

______________________________Date

ELECTRONIC PAYMENT AGREEMENT AUTHORIZATION

3. Automatic Checking Account Deduction(Monthly):

Your monthly premium will be deductedautomatically from the bank or credit unionchecking account you request.

If you are submitting cash with yourapplication you must enclose onemonths’ premium. Enclose a voidedblank check for the account you wish to use.

If using a credit union account, please providecredit union phone number.

Phone #: (______) _______________________

I authorize: (1) MetLife to initiate monthly deductions from my checking account, by electronic or other means, as payment for the coverage level selected; and (2) the financial institution on which my enclosed sample check(marked VOID) is drawn to: (a) accept the deductions initiated by MetLife; and (b) giveMetLife my most recent address upon MetLife’srequest. Deductions will continue until MetLife has had a reasonable opportunity to act upon mywritten request to end this service. I authorizedeductions to be taken on the day of the month, or the next business day. If no day is selected, deductions will be taken on the first business day of the month.

______________________________Signature of Account Holder for Monthly Automatic Deductions

______________________________Date


PART F REPLACEMENT QUESTIONS

LTC3-APP-CA 15



Is the policy in-force under a nonforfeiture benefit provision? Yes No

Is the policy in-force under anonforfeiture benefit provision? Yes No

1. Do you have another Long-Term Care Insurancepolicy or certificate in-force (including a healthcare service contract or a health maintenanceorganization contract)? Yes No

IF “YES” the types and amounts of coverage?

__________________________________________________________________________________

2. Did you have another Long-Term Care Insurancepolicy or certificate in-force during the lasttwelve (12) months? Yes No

IF “YES” with which insurance company?

__________________________________________________________________________________

If that policy or certificate lapsed, when did it lapse?

__________________________________________________________________________________

3. Are you covered under Medi-Cal?(“Medi-Cal” is different from “Medicare.”)

Yes No

4. Do you intend to replace any of yourlong-term care, medical or healthinsurance coverages with this policy? Yes No

IF “YES” please complete all information below andsign Replacement Notice in back of application:

Policy #:__________________________________

Insurance Company Name:___________________

Insurance Company Address: _________________

_________________________________________

_________________________________________

1. Do you have another Long-Term Care Insurancepolicy or certificate in-force (including a healthcare service contract or a health maintenanceorganization contract)? Yes No

IF “YES” the types and amounts of coverage?

__________________________________________________________________________________

2. Did you have another Long-Term Care Insurancepolicy or certificate in-force during the lasttwelve (12) months? Yes No

IF “YES” with which insurance company?

__________________________________________________________________________________

If that policy or certificate lapsed, when did it lapse?

__________________________________________________________________________________

3. Are you covered under Medi-Cal?(“Medi-Cal” is different from “Medicare.”)

Yes No

4. Do you intend to replace any of yourlong-term care, medical or healthinsurance coverages with this policy? Yes No

IF “YES” please complete all information below andsign Replacement Notice in back of application:

Policy #:__________________________________

Insurance Company Name:___________________

Insurance Company Address: _________________

_________________________________________

_________________________________________

You MUST answer all questions or We will not be able to process this application.State regulations require that We ask the following questions if you are applying for insurance.


PART G AGREEMENT AND ACKNOWLEDGEMENT


LTC3-APP-CA 17


SIGN

SIGN

SIGN

SIGN

REQUIRED INFORMATION

Please check to indicate that the Agent has deliveredthe following items:

Outline of Coverage for the policy applied for, which includes a graphic comparison of a policy with and without the 5% Automatic Compound Inflation Protection Rider

Taking Care of Tomorrow (Shopper’s Guide toLong-Term Care)

If this is a replacement policy, Replacement Notice

MetLife’s Consumer Privacy Notice

HICAP Notice

Long-Term Care Insurance Personal Worksheet

Information, including address and phone number of local HICAP office

Guide to Health Insurance for People with Medicare (if eligible for Medicare)

_____________________________________Signature of Applicant 1

_____________________________________Date

I have delivered all of the above documents to the Applicant.

_____________________________________Signature of Licensed and Appointed Agent

_____________________________________Date

(continued)

REQUIRED INFORMATION

Please check to indicate that the Agent has deliveredthe following items:

Outline of Coverage for the policy applied for, which includes a graphic comparison of a policy with and without the 5% Automatic Compound Inflation Protection Rider

Taking Care of Tomorrow (Shopper’s Guide toLong-Term Care)

If this is a replacement policy, Replacement Notice

MetLife’s Consumer Privacy Notice

HICAP Notice

Long-Term Care Insurance Personal Worksheet

Information, including address and phone number of local HICAP office

Guide to Health Insurance for People with Medicare (if eligible for Medicare)


_____________________________________Date

I have delivered all of the above documents to the Applicant.


_____________________________________Date

(continued)

PART G AGREEMENT AND ACKNOWLEDGEMENT (CONTINUED)


LTC3-APP-CA 18


1. Protection Against Unintended Lapse

I understand that I have the right to designate at leastone person other than myself to receive notice of lapseor termination of this Long-Term Care Insurance policyfor non-payment of premium. I understand that noticewill not be given until 30 days after a premium is dueand unpaid.

I designate the following person to receive noticeprior to cancellation of my policy for nonpayment of premium:

Full Name: _________________________________

Relationship: _______________________________

Address: ___________________________________

Apt.# ______ Telephone: (____) ________________

City: ______________________________________

State: ____________ Zip: _____________________

I elect NOT to designate any person to receive the notice.

Rejection of Compound Inflation Protection

I have reviewed the Outline of Coverage for thepolicy applied for, and the graphs that compare apolicy with and without the 5% AutomaticCompound Inflation Protection Rider. Specifically, I have reviewed options for Compound increase, and I reject the 5% Automatic Compound InflationProtection Rider.

Rejection of Nonforfeiture

I have reviewed the Outline of Coverage and theNonforfeiture Coverage Rider as described therein.Specifically, I have reviewed the plan withNonforfeiture Coverage and I reject the NonforfeitureCoverage Rider.

(continued)

1. Protection Against Unintended Lapse

I understand that I have the right to designate at leastone person other than myself to receive notice of lapseor termination of this Long-Term Care Insurance policyfor non-payment of premium. I understand that noticewill not be given until 30 days after a premium is dueand unpaid.

I designate the following person to receive noticeprior to cancellation of my policy for nonpayment of premium:

Full Name: _________________________________

Relationship: _______________________________

Address: ___________________________________

Apt.# ______ Telephone: (____) ________________

City: ______________________________________

State: ____________ Zip: _____________________

I elect NOT to designate any person to receive the notice.

Rejection of Compound Inflation Protection

I have reviewed the Outline of Coverage for thepolicy applied for, and the graphs that compare apolicy with and without the 5% AutomaticCompound Inflation Protection Rider. Specifically, I have reviewed options for Compound increase, and I reject the 5% Automatic Compound InflationProtection Rider.

Rejection of Nonforfeiture

I have reviewed the Outline of Coverage and theNonforfeiture Coverage Rider as described therein.Specifically, I have reviewed the plan withNonforfeiture Coverage and I reject the NonforfeitureCoverage Rider.

(continued)

PART G AGREEMENT AND ACKNOWLEDGEMENT (CONTINUED)


LTC3-APP-CA 19


I understand that if this is an application for a new policy (InitialCoverage), then except as stated in the Conditional PremiumReceipt, MetLife will have no liability until a policy is personallydelivered to me and the full first premium is paid.The policy will then be in effect, subject to the terms set forth in thenext paragraph. If this is an application for a coverage change thenthe coverage change will take effect on the effective date of thechange.I understand that: (1) the policy, if no Conditional Premium Receipthas been issued, or (2) any coverage change that I am applying for;will not take effect unless on the date the policy is delivered to meor on the date such coverage change would otherwise be effective:(a) the condition of my health is the same as given in this applica-tion; and (b) I have not received any medical advice or treatmentfrom a physician or other health care provider since the date of thisapplication. I agree that I will inform MetLife if there is a changein my health or if I have received any medical advice or treatment,as described above, between the date of this application and: (1) thedate the policy is delivered to me; or (2) the date on which any cov-erage change is scheduled to go into effect.Wherever my Initials appear in this application, it shall have thesame force and effect as if I had signed my name in full on the dateshown below.Your signature below confirms your request for coverage; con-firms your election concerning a Lapse Designee; and if yourejected Automatic Inflation Protection, confirms your review ofthe information above concerning Automatic Inflation Protectionand your rejection of Automatic Inflation Protection.Caution: If your answers or statements on this application aremisstated or untrue, MetLife may have the right to deny benefits orrescind your coverage.Fraud Warning: Any person who knowingly and with intent todefraud any insurance company or other person files an applicationfor insurance containing any materially false information, or con-ceals, for the purpose of misleading, information concerning anyfact material thereto, commits a fraudulent insurance act, which isa crime and subjects such person to criminal and civil penalties.I have read the above answers and statements on this Application.I declare all information supplied in this application is true andcomplete.


_____________________________________Date Signed at City, State



I understand that if this is an application for a new policy (InitialCoverage), then except as stated in the Conditional PremiumReceipt, MetLife will have no liability until a policy is personallydelivered to me and the full first premium is paid.The policy will then be in effect, subject to the terms set forth in thenext paragraph. If this is an application for a coverage change thenthe coverage change will take effect on the effective date of thechange.I understand that: (1) the policy, if no Conditional Premium Receipthas been issued, or (2) any coverage change that I am applying for;will not take effect unless on the date the policy is delivered to meor on the date such coverage change would otherwise be effective:(a) the condition of my health is the same as given in this applica-tion; and (b) I have not received any medical advice or treatmentfrom a physician or other health care provider since the date of thisapplication. I agree that I will inform MetLife if there is a changein my health or if I have received any medical advice or treatment,as described above, between the date of this application and: (1) thedate the policy is delivered to me; or (2) the date on which any cov-erage change is scheduled to go into effect.Wherever my Initials appear in this application, it shall have thesame force and effect as if I had signed my name in full on the dateshown below.Your signature below confirms your request for coverage; con-firms your election concerning a Lapse Designee; and if yourejected Automatic Inflation Protection, confirms your review ofthe information above concerning Automatic Inflation Protectionand your rejection of Automatic Inflation Protection.Caution: If your answers or statements on this application aremisstated or untrue, MetLife may have the right to deny benefits orrescind your coverage.Fraud Warning: Any person who knowingly and with intent todefraud any insurance company or other person files an applicationfor insurance containing any materially false information, or con-ceals, for the purpose of misleading, information concerning anyfact material thereto, commits a fraudulent insurance act, which isa crime and subjects such person to criminal and civil penalties.I have read the above answers and statements on this Application.I declare all information supplied in this application is true andcomplete.





SIGN

SIGN

SIGN

SIGN

AGENT’S REPORT


20


PLEASE PROVIDE COMPLETE DETAILS TO ENSURE AGAINST DELAYS IN PROCESSING THIS APPLICATION.

1.Did you personally interview theApplicant face to face and witnesshis or her signature? Yes No

IF “NO” give details:_________________________

____________________________________________________________________________________

2. If you answered “yes” to question 1,did you observe any physical or mentalimpairments with regard to theApplicant’s walking or talking,or any form of tremor? Yes No

IF “YES” please describe: _____________________

____________________________________________________________________________________

3.Please list other health insurance policies sold byyou to the Applicant that are still in-force:

____________________________________________________________________________________

4. List health insurance policies sold by you in the lastfive years to the Applicant that are no longer in-force:

____________________________________________________________________________________

5. UNDERWRITING: I have reviewed the underwritingguidelines and the information provided in thisapplication. The following risk class was quotedto the Applicant: Preferred Standard

6.APS ordered? Yes NoPhysician Name: _____________________________

Date Ordered:____________________(MM/DD/YY)Vendor Used:________________________________

7. Is this a replacement policy? (Ifyes, provide Replacement Notice) Yes No

8.Modal Premium $ ___________

Annualized Premium $ ___________(continued)

1.Did you personally interview theApplicant face to face and witnesshis or her signature? Yes No

IF “NO” give details:_________________________

____________________________________________________________________________________

2. If you answered “yes” to question 1,did you observe any physical or mentalimpairments with regard to theApplicant’s walking or talking,or any form of tremor? Yes No

IF “YES” please describe: _____________________

____________________________________________________________________________________

3.Please list other health insurance policies sold byyou to the Applicant that are still in-force:

____________________________________________________________________________________

4. List health insurance policies sold by you in the lastfive years to the Applicant that are no longer in-force:

____________________________________________________________________________________

5. UNDERWRITING: I have reviewed the underwritingguidelines and the information provided in thisapplication. The following risk class was quotedto the Applicant: Preferred Standard

6.APS ordered? Yes NoPhysician Name: _____________________________

Date Ordered:____________________(MM/DD/YY)Vendor Used:________________________________

7. Is this a replacement policy? (Ifyes, provide Replacement Notice) Yes No

8.Modal Premium $ ___________

Annualized Premium $ ___________(continued)

AGENT’S REPORT (CONTINUED)

21


Agency#/ DistributionPrint Name Firm Name Producer # SS# Percent Channel*

1st Rep. MLFSGenAm MLRGeneral Agent Other

2nd Rep. MLFSGenAm MLRGeneral Agent Other

3rd Rep. MLFSGenAm MLRGeneral Agent Other

*Please select the appropriate box based on the distribution channel you are submitting business under:

MLFS....MetLife Financial Services GenAm....General AmericanMLR....MetLife Resources General Agent....LTC Brokerage Other: _________________

9. CERTIFICATION:

I certify that each applicable question was personally asked of the Applicant(s) by me and that I have accurately recorded the information supplied by the Applicant(s). The Applicant(s) was (were) interviewed by me in person or by telephone and all answers on this application are correct and complete to the best of my knowledge and belief. I certify that any required written disclosure statement was given to theApplicant(s) no later than the date this application was signed.

I did not personally interview, by phone or face-to-face, the Applicant(s). I certify that any required written disclosure statement was given to the Applicant(s) no later than the date this application was signed.

_________________________________________ __________________________________________Signature of Licensed & Appointed Agent Name of Licensed & Appointed Agent (Please Print)

Offered through:* MLFS GenAm MLR General Agent Other ________________(other than GenAm) Firm Name

Office ID#____________________________ Producer #__________________ SS#______________________________

Street Address_________________________ Apt. #_______ City/State/Zip_____________________________________

Phone/Fax_________________________________________ e-mail address ____________________________________

10. For split commission cases, provide the information requested below, indicating the percentage ofcommission applicable to each:

YOU MUST COMPLETE THIS SECTION IF YOU ARE SUBMITTING BUSINESS THROUGH LTC BROKERAGE.

MGA Name___________________________MGA Code________________ MGA Address ________________________

MGA Phone #____________________Fax # __________________________ ___________________________________

MGA contact (for application status)____________________ e-mail (for application status) _________________________

BROKER HIERARCHY: Please list GA1 and AGA name/s and code/s if the broker does not roll up directly to the MGA.

IF SPLIT

AGA _____________________________________ AGA _______________________________________

GA1 _____________________________________ GA1 _______________________________________

Broker _____________________________________ Broker _______________________________________

Enter “pending” if code not yet assigned.

SIGN


CONDITIONAL PREMIUM RECEIPT


LTC3-APP-CR-CA 23

APPLICANT 1

Received fromName of Applicant 1 (Please print)

$ onAmount Date

THERE IS NO COVERAGE IN EFFECT UNDER THIS CONDITIONAL PREMIUM RECEIPT UNTILMETLIFE APPROVES THE APPLICATION.

It is understood and agreed that payment of the premium shown above under this Conditional Premium Receipt is madeand accepted subject to the following conditions:

1. If, after We (Metropolitan Life Insurance Company (“MetLife”)) receive: (a) the Initial Application Requirements, asdefined below; and (b) evidence of insurability acceptable to Us, We determine that as of the date of the application,you are insurable based upon Our underwriting criteria and standards for the insurance coverage applied for, thepolicy will take effect. In the event that all of the conditions in the preceding sentence are satisfied, coverageunder this Conditional Receipt will take effect on the Application Date and the coverage shall be governed bythe terms and conditions of the policy applied for in the Application. Any changes in your health after the dateof this Receipt will not affect Our underwriting decision.

2. If We issue a policy to you, any unpaid balance of the first full premium due, in accordance with the premiumpayment mode you have selected, must be paid upon delivery of the policy.

For purposes of this Receipt, the Initial Application Requirements are:

1. Completion of the application, in which you have answered “No” to all Questions in Part B of the application.

2. Completion of an acceptable underwriting assessment, nurse interview, physical examination and assessment,if required by Us.

3. Receipt by Us of any Attending Physician Statement(s), medical records and any other medical documents that Wemay require.

4. The full amount of any check, draft or money order paid under this Receipt must be honored on its first presentationfor payment.

CAUTION: Your answers to all Questions in Part B of the application are relied upon to accept payment and issue this Receipt. If any of these answers are incomplete or incorrect, or MetLife is unable to approve the application within60 days from the date of the application, the amount paid will be returned and this Receipt will be null and void from the beginning.

If We determine that as of the date of the application you are not eligible for the insurance coverage applied for, coverageunder this Receipt will not become effective. There will be no coverage under the Conditional Premium Receipt and theamount paid will be returned to you.

Limitations on Authority: No one but the President, the Secretary or a Vice-President of MetLife may change or waivethe terms of this Conditional Premium Receipt. No agent, financial services representative or medical examiner hasauthority to determine insurability or to make or modify any contract of insurance or waive any of Our requirements.

LTC3-APP-CR-CA 24

CONDITIONAL PREMIUM RECEIPT (CONTINUED)


APPLICANT 1

I have read this Conditional Premium Receipt, and reviewed my answers to all Questions in Part B of the application. I represent that the answers to all those Questions are true and complete. I understand and agree that if the answers to any of the Questions in Part B of the application are not true and complete, the amount tenderedwill be returned and this Conditional Premium Receipt will be null and void from the beginning. I understand and agree to all of the terms of this Conditional Premium Receipt. I have received a copy of this ConditionalPremium Receipt.

_____________________________________________ __________________Signature of Applicant 1 Date

No agent or financial services representative is authorized to accept any payment with the application if youanswered “Yes” (or left blank) to any of the Questions in Part B of your application.

Receipt of $ is acknowledged from

in connection with the application for Long-Term Care Insurance on this date By:

______________________________________________Signature of Authorized Agent

Metropolitan Life Insurance Company

Gwenn L. Carr

Vice-President and Secretary

MetLife makes no representations as to the tax consequences of premium paid under this Receipt or the Benefitsyou receive under this Receipt. Consult your own legal or tax advisor.

ALL CHECKS MUST BE MADE PAYABLE TO METROPOLITAN LIFE INSURANCE COMPANY.DO NOT MAKE CHECK PAYABLE TO THE AGENT OR LEAVE THE PAYEE BLANK.

SIGN

SIGN


SIGN & LEAVE THIS PAGE WITH APPLICANT

LTC3-APP-CR-CA 25


$ onAmount Date













APPLICANT 1

LTC3-APP-CR-CA 26



APPLICANT 1


__________________________________ __________________Signature of Applicant 1 Date




______________________________________________Signature of Authorized Agent


Gwenn L. Carr




SIGN

SIGN



LTC3-APP-CR 27

APPLICANT 2


$ on Amount Date













LTC3-APP-CR 28



APPLICANT 2






______________________________________________Signature of Agent


Gwenn L. Carr




SIGN

SIGN



LTC3-APP-CR-CA 29


$ onAmount Date













APPLICANT 2



APPLICANT 2






_______________________________________________

Signature of Authorized Agent


Gwenn L. Carr




SIGN

SIGN

30

AUTHORIZATION TO RELEASE INFORMATION TO METLIFE

APPLICANT 1

HIPAA: This Authorization has been carefully and specifically drafted to permit disclosure of health information consistent with the privacy rules adopted and subsequently amended by the United States Department of Health andHuman Services pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

LTC3-APP-AUTH-CA 31


SIGN

In connection with my application for a long-term care insurance policy, for underwriting and claim purposes,I authorize any medical practitioner or facility or related entity; any insurer; employer; group policyholder, contract holder,or benefit plan administrator to give Metropolitan Life Insurance Company (“MetLife”) or any third party acting onMetLife's behalf in this regard:

• personal information and data about me;• the entire medical file for the last three years, including medical information, records and data, about me, including

information such as office visits, outpatient treatment, drugs prescribed, medical test results and sexually transmitteddiseases and similar information;

• information, records and data about me related to alcohol and drug abuse and treatment, including information, recordsand data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2;

• information, records and data about me relating to Acquired Immune Deficiency Syndrome (AIDS) or AIDS relatedconditions; and

• information, records and data about me relating to mental illness, other than psychotherapy notes.

Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form orsooner if prescribed by law. I understand that, unless permitted by applicable law, I cannot revoke this authorization: (1) tothe extent that MetLife has taken action relying on the authorization; or (2) if MetLife obtained the authorization as a con-dition to my obtaining insurance coverage. In all other cases, I understand that I may revoke it at any time. To revoke theauthorization, I must write to MetLife at MetLife HIPAA Authorizations, P.O. Box 64911, St. Paul, MN 55164-0911 andinform MetLife that this Authorization is revoked. Any action taken before MetLife receives my revocation will be valid.Revocation may be the basis for denying coverage or benefits. If I do not sign this Authorization, my application for longterm care insurance cannot be processed.

By signing below, I acknowledge my understanding that:• All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to andused by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insur-ance applied for or on existing insurance with MetLife without my authorization as permitted by applicable law.• Medical information, records and data that may have been subject to federal and state laws or regulations, including federal

rules issued by Health and Human Services, setting forth standards for the use, maintenance and disclosure of such informa-tion by health care providers and health plans and records and data related to alcohol and drug abuse protected by FederalRegulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by MetLife, may no longer be covered by thoselaws or regulations.

• Information about me, including medical information, records and data, may be disclosed to the California Department ofHealth or other health oversight agency and to other parties without my authorization, as required or otherwise permitted byapplicable law.

• Information obtained pursuant to this authorization about me may be used, to the extent permitted by applicable law, todetermine the insurability of other family members.

• Information relating to HIV test results will only be disclosed as permitted by applicable law.• I have a right to receive a copy of this form.

A photocopy of this form is as valid as the original form.

__________________________________________ _______________________________Applicant 1 Name (print) Date of Birth

__________________________________________ _______________________________Signature of Applicant 1 Date


APPLICANT 2


















SIGN

LTC3-APP-AUTH-CA 32


APPLICANT 1


LTC3-APP-AUTH-CA 33

















SIGN



APPLICANT 2


LTC3-APP-AUTH-CA 35

















SIGN


CALIFORNIA AUTHORIZATION TO RELEASE INFORMATION

APPLICANT 1

37 CA AUTH


SIGN__________________________________________ _______________________________Signature of Applicant 1 Date

Under California law, if your application is denied or if coverage is issued at less than our best rateon the basis of medical record information (other than mental health record information), you maychoose to have such information released directly to you or to a medical professional.* If you wouldlike MetLife to send this information directly to you please provide your signature below. At time ofdecision you will receive the specific health information that was the basis for the decision, alongwith an “Information Rights Flyer”.

If you would prefer that MetLife send specific medical record information to your physician do notsign below. You will be asked to provide us with the physician’s name you wish to receive the information that was the basis for the decision in the event your application is denied or that coverageis issued at a premium rate other than the company’s best rate. You will also receive instructions howto proceed, along with an "Information Rights Flyer".

* The release of mental health record information directly to you is, under California law, subject tothe prior approval of the qualified professional person with treatment responsibility for the condi-tion to which the information relates.

I authorize MetLife to disclose my health information directly to me.



APPLICANT 1

39 CA AUTH









APPLICANT 2

41 CA AUTH









APPLICANT 2

43 CA AUTH








APPLICANT 1



If you submit a request for insurance (application or enrollment form) we will evaluate it. We will reviewthe information you give to us and we may confirm it or add to it in the ways explained below.

This Privacy Notice is given to you on behalf of Metropolitan Life Insurance Company (MetLife).

Please Read This Privacy Notice Carefully. It describes how we learn about you and how we treat the informa-tion we collect about you. (If anyone else is to be insured under the coverage you request, what we say here alsoapplies to information about them.)

Why We Need Information: We need to know about you (and anyone else to be insured) so that we can providethe insurance and other products and services you’ve asked for. We may also need it to administer your businesswith us, evaluate claims, process transactions and run our business. And we need information from you and others to help us verify identities in order to prevent money laundering and terrorism.

What we need to know includes address, age and other basic information. But we may need more information,including finances, employment, health, hobbies or business conducted with us, with other MetLife companies (our "affiliates") or with other companies.

How We Get Information: What we know about you (and anyone else to be insured) we get mostly from you.But we may also have to find out more from other sources in order to make sure that what we know is correctand complete. Those sources may include adult relatives, employers, health care providers and others. TheAuthorization that you sign when you applied for insurance permits these sources to tell us about you. So wemay, for instance, at our expense:

• Ask for a medical exam

• Ask for blood and urine tests

• Ask health care providers to give us health data, including information about alcohol or drug abuse

How We Protect What We Know: We treat what we know about you confidentially. Our employees are told totake care in handling your information. They may get information about you only when there is a good reason todo so. We take steps to make our computer data bases secure and to safeguard the information we have.

How We Use and Disclose What We Know About You: We may use what we know about you to help us serveyou better. We may use it, and disclose it to our affiliates and others, for any purpose allowed by law. Forinstance, we may use your information, and disclose it to others, in order to:

• Help us evaluate your request for a product or service • Help us run our business

• Help us process claims and other transactions • Process information for us

• Confirm or correct what we know about you • Perform research for us

• Help us prevent fraud and other crimes • Audit our business

• Help us comply with the law • Tell a group customer about its members’ claimsor cooperating in a group customer’s audit ofour service

Other reasons we may disclose what we know about you include:• Doing what a court or government agency requires us to do; for example, complying with a search

warrant or subpoena• Telling another company what we know about you, if we are or may be selling all or any part of our

business or merging with another company• Giving information to the government so that it can decide whether you may get benefits that it will have

to pay for

CONSUMER PRIVACY NOTICE

45 LTC3-APP

CONSUMER PRIVACY NOTICE (CONTINUED)

46 LTC3-APP


• Telling your health care provider about a medical problem that you have but may not be aware of• Giving your information to a peer review organization if you have health insurance with us• Giving your information to someone who has a legal interest in your insurance, such as someone who lent

you money and holds a lien on your policyGenerally, we will disclose only the information we consider reasonably necessary to disclose.

How We Use and Disclose What We Know About You to Offer You Other Products and Services:

THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT ("HIPAA") PROTECTS YOURINFORMATION IF YOU REQUEST OR PURCHASE LONG-TERM CARE INSURANCE FROM US. IN ADDITION TO THE LIMITATIONS DESCRIBED IN THIS SECTION"HOW WE USE AND DISCLOSE WHATWE KNOW ABOUT YOU TO OFFER YOU OTHER PRODUCTS AND SERVICES," HIPAA FURTHER LIMITS OUR ABILITY TO USE AND DISCLOSE THE INFORMATION THAT WE OBTAIN AS A RESULT OFYOUR REQUEST OR PURCHASE OF LONG-TERM CARE INSURANCE. INFORMATION ABOUT YOURRIGHTS UNDER HIPAA WILL BE PROVIDED TO YOU WITH ANY LONG-TERM CARE COVERAGE ISSUEDTO YOU. FOR MORE INFORMATION SEE THE LAST PARAGRAPH OF THIS NOTICE.

We may use what we know about you in order to offer you our other products and services. We may disclose thisinformation (other than consumer reports and health information):

• to our affiliates so that they can offer their products and services, or ours, to you. Unless applicable law requiresotherwise we don’t have to let you prevent these disclosures. Our affiliates include life, car and home insurers,securities firms, broker-dealers, a bank, a legal plans company and financial advisors. In the future, we mayhave affiliates in other businesses.

• to others outside of the MetLife companies, such as marketing companies, to help us offer our products andservices to you.

• to other financial services companies, if we have joint marketing agreements with them so that they canoffer their products and services to you. Except for joint marketing arrangements, we do not make anyother disclosures of your information to other companies who want to sell their products or services to you.For example, we will not sell your name to a catalog company.

You Can See and Correct Your Information:Generally, we will let you review what we know about you if you ask us in writing. (Because of its legal sensitivity, we will not show you anything that we learned in connection with a claim or lawsuit.) Also, if the law allows us to do so, we may decide to disclose what we know about your health only through your health care provider. If you tell us that what we know about you is incorrect, we will review it. If we agree with you, we will correct our records. If we do not agree with you, you may tell us in writing, and we will include your statement when we give your information to anyone outside MetLife.

You Can Get Other Material from Us: This is a general description of MetLife’s information practices. We treat your information in accordance with applicable laws. You may have other rights under the law. For example,individuals who request or purchase Long-Term Care Insurance coverage from us have rights under HIPAA. For additional information about your rights under HIPAA, or, for other information about privacy please contact us at our website, www.metlife.com, or write to MetLife, P.O. Box 64911, St. Paul, MN 55164-0911.


APPLICANT 1

APPLICANT 2

47 LTC3-APP



If you submit a request for insurance (application or enrollment form) we will evaluate it. We will reviewthe information you give to us and we may confirm it or add to it in the ways explained below.

This Privacy Notice is given to you on behalf of Metropolitan Life Insurance Company (MetLife).

Please Read This Privacy Notice Carefully. It describes how we learn about you and how we treat the informa-tion we collect about you. (If anyone else is to be insured under the coverage you request, what we say here alsoapplies to information about them.)

Why We Need Information: We need to know about you (and anyone else to be insured) so that we can providethe insurance and other products and services you’ve asked for. We may also need it to administer your businesswith us, evaluate claims, process transactions and run our business. And we need information from you and others to help us verify identities in order to prevent money laundering and terrorism.

What we need to know includes address, age and other basic information. But we may need more information,including finances, employment, health, hobbies or business conducted with us, with other MetLife companies (our "affiliates") or with other companies.

How We Get Information: What we know about you (and anyone else to be insured) we get mostly from you.But we may also have to find out more from other sources in order to make sure that what we know is correctand complete. Those sources may include adult relatives, employers, health care providers and others. TheAuthorization that you sign when you applied for insurance permits these sources to tell us about you. So wemay, for instance, at our expense:

• Ask for a medical exam

• Ask for blood and urine tests

• Ask health care providers to give us health data, including information about alcohol or drug abuse

How We Protect What We Know: We treat what we know about you confidentially. Our employees are told totake care in handling your information. They may get information about you only when there is a good reason todo so. We take steps to make our computer data bases secure and to safeguard the information we have.

How We Use and Disclose What We Know About You: We may use what we know about you to help us serveyou better. We may use it, and disclose it to our affiliates and others, for any purpose allowed by law. Forinstance, we may use your information, and disclose it to others, in order to:

• Help us evaluate your request for a product or service • Help us run our business

• Help us process claims and other transactions • Process information for us

• Confirm or correct what we know about you • Perform research for us

• Help us prevent fraud and other crimes • Audit our business

• Help us comply with the law • Tell a group customer about its members’ claimsor cooperating in a group customer’s audit ofour service

Other reasons we may disclose what we know about you include:• Doing what a court or government agency requires us to do; for example, complying with a search

warrant or subpoena• Telling another company what we know about you, if we are or may be selling all or any part of our

business or merging with another company• Giving information to the government so that it can decide whether you may get benefits that it will have

to pay for

CONSUMER PRIVACY NOTICE

CONSUMER PRIVACY NOTICE (CONTINUED)

48 LTC3-APP


• Telling your health care provider about a medical problem that you have but may not be aware of• Giving your information to a peer review organization if you have health insurance with us• Giving your information to someone who has a legal interest in your insurance, such as someone who lent

you money and holds a lien on your policyGenerally, we will disclose only the information we consider reasonably necessary to disclose.

How We Use and Disclose What We Know About You to Offer You Other Products and Services:

THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT ("HIPAA") PROTECTS YOURINFORMATION IF YOU REQUEST OR PURCHASE LONG-TERM CARE INSURANCE FROM US. IN ADDITION TO THE LIMITATIONS DESCRIBED IN THIS SECTION"HOW WE USE AND DISCLOSE WHATWE KNOW ABOUT YOU TO OFFER YOU OTHER PRODUCTS AND SERVICES," HIPAA FURTHER LIMITS OUR ABILITY TO USE AND DISCLOSE THE INFORMATION THAT WE OBTAIN AS A RESULT OFYOUR REQUEST OR PURCHASE OF LONG-TERM CARE INSURANCE. INFORMATION ABOUT YOURRIGHTS UNDER HIPAA WILL BE PROVIDED TO YOU WITH ANY LONG-TERM CARE COVERAGE ISSUEDTO YOU. FOR MORE INFORMATION SEE THE LAST PARAGRAPH OF THIS NOTICE.

We may use what we know about you in order to offer you our other products and services. We may disclose thisinformation (other than consumer reports and health information):

• to our affiliates so that they can offer their products and services, or ours, to you. Unless applicable law requiresotherwise we don’t have to let you prevent these disclosures. Our affiliates include life, car and home insurers,securities firms, broker-dealers, a bank, a legal plans company and financial advisors. In the future, we mayhave affiliates in other businesses.

• to others outside of the MetLife companies, such as marketing companies, to help us offer our products andservices to you.

• to other financial services companies, if we have joint marketing agreements with them so that they canoffer their products and services to you. Except for joint marketing arrangements, we do not make anyother disclosures of your information to other companies who want to sell their products or services to you.For example, we will not sell your name to a catalog company.

You Can See and Correct Your Information:Generally, we will let you review what we know about you if you ask us in writing. (Because of its legal sensitivity, we will not show you anything that we learned in connection with a claim or lawsuit.) Also, if the law allows us to do so, we may decide to disclose what we know about your health only through your health care provider. If you tell us that what we know about you is incorrect, we will review it. If we agree with you, we will correct our records. If we do not agree with you, you may tell us in writing, and we will include your statement when we give your information to anyone outside MetLife.

You Can Get Other Material from Us: This is a general description of MetLife’s information practices. We treat your information in accordance with applicable laws. You may have other rights under the law. For example,individuals who request or purchase Long-Term Care Insurance coverage from us have rights under HIPAA. For additional information about your rights under HIPAA, or, for other information about privacy please contact us at our website, www.metlife.com, or write to MetLife, P.O. Box 64911, St. Paul, MN 55164-0911.


APPLICANT 2

Complete this page forREPLACEMENT POLICIES only


APPLICANT 1APPLICANT 1

AGEN

T D

ETAC

H H

ERE

49 LTC3-APP 49 LTC3-APP

SIGN & MAIL THIS PAGE TO METLIFESIGN & LEAVE THIS PAGE WITH APPLICANT

If Part F, question #4 is answeredYES, complete this Notice and leavea copy with the Applicant.

NOTICE TO APPLICANT REGARDING REPLACEMENT OFACCIDENT AND SICKNESS OR LONG-TERM CARE (LTC)INSURANCE. SAVE THIS NOTICE! IT MAY BE IMPORTANTTO YOU IN THE FUTURE. According to your application, you intendto lapse or otherwise terminate existing accident and sickness insurance orLong-Term Care Insurance coverage and replace it with an individualLong-Term Care Insurance policy issued by Metropolitan Life InsuranceCompany. Your new policy provides thirty (30) days within which youmay decide, without cost, whether you desire to keep the policy. For yourown information and protection, you should be aware of and seriously con-sider certain factors which may affect the insurance protection available toyou under the new policy. You should review this new coverage carefully,comparing it with all accident and sickness or Long-Term Care Insurancecoverage you now have, and terminate your present policy only if, after dueconsideration, you find that purchase of this Long-Term Care Insurancecoverage is a wise decision.STATEMENT TO APPLICANT BY AGENT: (Use additional sheetsas necessary.) I have reviewed your current medical, health, and LTCinsurance coverage. I believe the replacement of insurance involved in thistransaction materially improves your position. My conclusion has takeninto account the following considerations, which I call to your attention:1. The policy has no exclusion for pre-existing conditions. This means

that health conditions which you may presently have are fully andimmediately covered under the new policy, if such policy is issued.

2. In many states, state law provides that your replacement policy may notcontain new pre-existing conditions or probationary periods. The pol-icy you are applying for has no such pre-existing conditions orprobationary periods.

3. Since you are planning to replace medical, health, or LTC insurancecoverage, you may wish to secure the advice of your present insurer orits agent regarding the proposed replacement of your present coverage.This is not only your right, but it is also in your best interest to makesure you understand all the relevant factors involved in replacing yourpresent coverage.

4. If, after you have thought about it, you still wish to terminate your pres-ent coverage and replace it with a new policy, be certain to truthfullyand completely answer all questions on the application concerning yourmedical health history. Failure to include all material medical infor-mation on an application may provide a basis for the company to denyany future claims and to refund your premium as though your policyhad never been in force. After the application has been completed andbefore you sign it, reread it carefully to be certain that all informationhas been properly recorded.

Signature of Sales Representative, Agent or Broker

Print Name and Address of Sales Representative, Agent or Broker

The above “Notice to Applicant” was delivered to me on: Date

Signature of Applicant 1










Signature of Applicant 1SIGN

SIGN

SIGN

SIGN

THIS PAGE IS INTENTIONALLY LEFT BLANK. THIS PAGE IS INTENTIONALLY LEFT BLANK.



APPLICANT 2APPLICANT 2

AGEN

T D

ETAC

H H

ERE

51 LTC3-APP 51 LTC3-APP

SIGN & MAIL THIS PAGE TO METLIFESIGN & LEAVE THIS PAGE WITH APPLICANT










Signature of Applicant 2










Signature of Applicant 2SIGN

SIGN

SIGN

SIGN

THIS PAGE IS INTENTIONALLY LEFT BLANK. THIS PAGE IS INTENTIONALLY LEFT BLANK.

LTC BENEFICIARY DESIGNATION FORM FOR RETURN OF PREMIUM RIDER

53 LTC3-BDF

MAIL THIS FORM TO METLIFE

BENEFICIARY DESIGNATIONFull Name (Last, Relationship Social Security Date Address Telephone Share %First, Middle Initial) Number of Birth (Street, City, State, Zip) Number

This form needs to be completed if you want to designate a beneficiary. If you do not want to designate abeneficiary, you do not need to complete this form and MetLife will return premiums under the Return ofPremium Rider (“Rider”) to your estate in the event of your death. Selecting a beneficiary may have taximplications for you or your beneficiary. Please consult your Tax Advisor for any tax implications of yourbeneficiary designation for the Rider.

IMPORTANT NOTE: If the beneficiary(ies) you designate is a minor at the time of your death, the amount payable to such beneficiary(ies) shall be made to your estate rather than to that beneficiary(ies).

Applicant Name: Applicant Social Security No.:

Please make sure to check only one of the following three boxes and complete any necessary accompanying information.

Individual Beneficiary(ies)I name the following Revocable Beneficiary(ies) to receive any amount payable under the policy in the event of my death:

(continued)

TOTAL: 100%

APPLICANT 1

LTC BENEFICIARY DESIGNATION FORM (CONTINUED)

SIGN & MAIL THIS FORM TO METLIFE

If no beneficiary designated shall be living following the insured’s death or is otherwise not able to receive theamount payable (e.g. minor), the amount that would have been payable to such beneficiary shall be paid to theinsured’s estate. If more than one beneficiary is selected, and one or more, but not all of such beneficiaries aredeceased at the time of the insured’s death or otherwise not able to receive the amount payable (e.g. minor), theamount that would have been payable to such beneficiary(ies) shall be paid to the insured’s estate.

Trust(ee) Designation (applies only if a trust has been created in an executed trust agreement)

Name of Trustee(s) ______________________________________________________________________

Address ____________________________ City ______________ State ____ Zip Code ____________

and successor(s) in trust, as Trustee(s) under ________________________________________________(“Title of the Trust Agreement”)

Dated ______________________________ and executed by me and said Trustee(s).

If MetLife receives proof satisfactory to it that the aforesaid trust has been revoked or is not in effect at the time of the insured’s death, I hereby designate my estate as beneficiary.

Trust(ee) (Under Will) Designation (applies only if a trust has been set forth in your Will)The trust(ee) under any last Will and Testament of mine as shall be admitted to probate.

If for any reason whatsoever, no Trust(ee) under any such last Will and Testament shall be duly appointed, I hereby designate my estate as beneficiary.

I understand and agree that any payment made in good faith by MetLife to the legal representative of my estate,pursuant to my designation of a beneficiary choice on this form shall be full discharge of the liability of MetLifewith respect to the Return of Premium Rider under the Policy. Further I understand that the refund of premi-ums on death is not assignable, cannot be pledged or used as collateral for a loan etc; and any beneficiarydesignation I make is revocable by me prior to my death, but only by completing a MetLife “BeneficiaryDesignation Change Request Form” available by calling our Customer Service line at (888) 565-3761.

Print Name

Signature Date

SIGN

54 LTC3-BDF

APPLICANT 1

LTC BENEFICIARY DESIGNATION FORM FOR RETURN OF PREMIUM RIDER

55 LTC3-BDF


BENEFICIARY DESIGNATIONFull Name (Last, Relationship Social Security Date Address Telephone Share %First, Middle Initial) Number of Birth (Street, City, State, Zip) Number

This form needs to be completed if you want to designate a beneficiary. If you do not want to designate abeneficiary, you do not need to complete this form and MetLife will return premiums under the Return ofPremium Rider (“Rider”) to your estate in the event of your death. Selecting a beneficiary may have taximplications for you or your beneficiary. Please consult your Tax Advisor for any tax implications of yourbeneficiary designation for the Rider.

IMPORTANT NOTE: If the beneficiary(ies) you designate is a minor at the time of your death, the amount payable to such beneficiary(ies) shall be made to your estate rather than to that beneficiary(ies).

Applicant Name: Applicant Social Security No.:

Please make sure to check only one of the following three boxes and complete any necessary accompanying information.

Individual Beneficiary(ies)I name the following Revocable Beneficiary(ies) to receive any amount payable under the policy in the event of my death:

(continued)

TOTAL: 100%

APPLICANT 2

LTC BENEFICIARY DESIGNATION FORM (CONTINUED)


If no beneficiary designated shall be living following the insured’s death or is otherwise not able to receive theamount payable (e.g. minor), the amount that would have been payable to such beneficiary shall be paid to theinsured’s estate. If more than one beneficiary is selected, and one or more, but not all of such beneficiaries aredeceased at the time of the insured’s death or otherwise not able to receive the amount payable (e.g. minor), theamount that would have been payable to such beneficiary(ies) shall be paid to the insured’s estate.

Trust(ee) Designation (applies only if a trust has been created in an executed trust agreement)

Name of Trustee(s) ______________________________________________________________________

Address ____________________________ City ______________ State ____ Zip Code ____________

and successor(s) in trust, as Trustee(s) under ________________________________________________(“Title of the Trust Agreement”)

Dated ______________________________ and executed by me and said Trustee(s).

If MetLife receives proof satisfactory to it that the aforesaid trust has been revoked or is not in effect at the time of the insured’s death, I hereby designate my estate as beneficiary.

Trust(ee) (Under Will) Designation (applies only if a trust has been set forth in your Will)The trust(ee) under any last Will and Testament of mine as shall be admitted to probate.

If for any reason whatsoever, no Trust(ee) under any such last Will and Testament shall be duly appointed, I hereby designate my estate as beneficiary.

I understand and agree that any payment made in good faith by MetLife to the legal representative of my estate,pursuant to my designation of a beneficiary choice on this form shall be full discharge of the liability of MetLifewith respect to the Return of Premium Rider under the Policy. Further I understand that the refund of premi-ums on death is not assignable, cannot be pledged or used as collateral for a loan etc; and any beneficiarydesignation I make is revocable by me prior to my death, but only by completing a MetLife “BeneficiaryDesignation Change Request Form” available by calling our Customer Service line at (888) 565-3761.

Print Name

Signature Date

SIGN

56 LTC3-BDF

APPLICANT 2

LONG-TERM CARE INSURANCE REPLACEMENT CHECKLIST

57 LTC3-RCL


APPLICANT 1

To be completed by Applicant:I have reviewed this form with my producer.

Signature of Applicant

Name of Applicant (Please Print)

Street Address

City

State Zip

To be completed by Licensed and AppointedProducer: I certify that each question was asked of the applicant and answered as recorded.

Signature of Licensed and Appointed Producer

Name of Licensed and Appointed Producer (Please Print)

Phone Fax

Street Address

City

State Zip

(over please)

COMPLETE FOR REPLACEMENTS INVOLVING METLIFE LONG-TERM CARE INSURANCETo be completed by Producer & Submitted with Application

Features: Existing Policy: Proposed Replacement ScoreCompany: MetLife Individual Business

1. Nursing Facility orComprehensive orHome Health Care

2. Home Health CarePercent of NursingFacilityDailyBenefitAmount (DBA)

3. Policy Duration

4. Inflation Protection

TOTAL SCORE

CHECK ONE:

• IF VALUE OF SCORE IS A POSITIVE NUMBER (+), then the benefits of the MetLife ReplacementPolicy may be considered Better or Greater than the benefits of the Existing Policy

• If Value of score is ZERO (0) or is a NEGATIVE NUMBER (-), then the benefits of the MetLifeReplacement Policy may not be considered Better or Greater than the benefits of the Existing Policy.

LONG-TERM CARE INSURANCE REPLACEMENT CHECKLIST (CONTINUED)


58 LTC3-RCL

APPLICANT 1

REPLACEMENT CHECKLIST

Instructions for Comparison & Scoring:Complete All Questions – Respond on Page 48, Total Score, Complete Applicant & Producer Information,Return Form with Application.

1. Indicate the Policy Coverages: Home Health Care OR Nursing Facility OR Comprehensive (Both

Nursing Facility & Home Health Care)

Score: Comprehensive is GREATER than Nursing Home which is GREATER than Home Health Care

• If MetLife’s Coverage is > Existing Policy Coverage,------------then score = +1

• If MetLife’s Coverage is = Existing Policy Coverage,------------then score = 0

• If MetLife’s Coverage is < Existing Policy Coverage,-------------then score = -1

If both policies provide comprehensive coverage, then complete #2, if not, skip to #3.

2. Home Health Care Percentage (HHC%) – Indicate Amount of Home Health Care as a percentage ofNursing Facility Daily Benefit Amount (DBA)

Score: HIGHER percentage provides more coverage

• If MetLife’s Policy HHC% is > Existing Policy Coverage HHC%,-------------------------then score = +1

• If MetLife’s Policy HHC% home care DBA is = Existing Policy Coverage HHC%,-----then score = 0

• If MetLife’s Policy HHC% home care DBA is < Existing Policy Coverage HHC%,-----then score = -1

3. Total Lifetime Duration – Indicate total policy duration: Number of years (e.g., 2 years, 3 years, etc.)

Score: A LONGER duration provides more coverage

• If MetLife’s Policy Duration is > Existing Policy Duration,-------------------------then score = +1

• If MetLife’s Policy Duration is = Existing Policy Duration,-------------------------then score = 0

• If MetLife’s Policy Duration is < Existing Policy Duration,-------------------------then score = -1

4. Inflation Option – Determine Inflation Protection Under Policy

Score: Compound Inflation provides more inflation protection then Simple, Optional or None

Simple Inflation provides more inflation protection than Optional or No Inflation Protection

Optional Inflation provides more inflation protection than No Inflation Protection

• If MetLife’s Policy Inflation Protection is > Existing Policy Inflation Protection,--------then score = +1

• If MetLife’s Policy Inflation Protection is = Existing Policy Inflation Protection,--------then score = 0

• If MetLife’s Policy Inflation Protection is , Existing Policy Inflation Protection,-------------------then score = -1

Complete This Section:

ANNUAL PREMIUM:

Existing Policy $_________________ Replacement Policy $_______________ Difference $_______________

LONG-TERM CARE INSURANCE REPLACEMENT CHECKLIST

59 LTC3-RCL


APPLICANT 2

To be completed by Applicant:I have reviewed this form with my producer.

Signature of Applicant

Name of Applicant (Please Print)

Street Address

City

State Zip

To be completed by Licensed and AppointedProducer: I certify that each question was asked of the applicant and answered as recorded.

Signature of Licensed and Appointed Producer

Name of Licensed and Appointed Producer (Please Print)

Phone Fax

Street Address

City

State Zip

(over please)

COMPLETE FOR REPLACEMENTS INVOLVING METLIFE LONG-TERM CARE INSURANCETo be completed by Producer & Submitted with Application

Features: Existing Policy: Proposed Replacement ScoreCompany: MetLife Individual Business

1. Nursing Facility orComprehensive orHome Health Care

2. Home Health CarePercent of NursingFacilityDailyBenefitAmount (DBA)

3. Policy Duration

4. Inflation Protection

TOTAL SCORE

CHECK ONE:

• IF VALUE OF SCORE IS A POSITIVE NUMBER (+), then the benefits of the MetLife ReplacementPolicy may be considered Better or Greater than the benefits of the Existing Policy

• If Value of score is ZERO (0) or is a NEGATIVE NUMBER (-), then the benefits of the MetLifeReplacement Policy may not be considered Better or Greater than the benefits of the Existing Policy.

LONG-TERM CARE INSURANCE REPLACEMENT CHECKLIST (CONTINUED)


60 LTC3-RCL

APPLICANT 2

REPLACEMENT CHECKLIST

Instructions for Comparison & Scoring:Complete All Questions – Respond on Page 48, Total Score, Complete Applicant & Producer Information,Return Form with Application.

1. Indicate the Policy Coverages: Home Health Care OR Nursing Facility OR Comprehensive (Both

Nursing Facility & Home Health Care)

Score: Comprehensive is GREATER than Nursing Home which is GREATER than Home Health Care

• If MetLife’s Coverage is > Existing Policy Coverage,------------then score = +1

• If MetLife’s Coverage is = Existing Policy Coverage,------------then score = 0

• If MetLife’s Coverage is < Existing Policy Coverage,-------------then score = -1

If both policies provide comprehensive coverage, then complete #2, if not, skip to #3.

2. Home Health Care Percentage (HHC%) – Indicate Amount of Home Health Care as a percentage ofNursing Facility Daily Benefit Amount (DBA)

Score: HIGHER percentage provides more coverage

• If MetLife’s Policy HHC% is > Existing Policy Coverage HHC%,-------------------------then score = +1

• If MetLife’s Policy HHC% home care DBA is = Existing Policy Coverage HHC%,-----then score = 0

• If MetLife’s Policy HHC% home care DBA is < Existing Policy Coverage HHC%,-----then score = -1

3. Total Lifetime Duration – Indicate total policy duration: Number of years (e.g., 2 years, 3 years, etc.)

Score: A LONGER duration provides more coverage

• If MetLife’s Policy Duration is > Existing Policy Duration,-------------------------then score = +1

• If MetLife’s Policy Duration is = Existing Policy Duration,-------------------------then score = 0

• If MetLife’s Policy Duration is < Existing Policy Duration,-------------------------then score = -1

4. Inflation Option – Determine Inflation Protection Under Policy

Score: Compound Inflation provides more inflation protection then Simple, Optional or None

Simple Inflation provides more inflation protection than Optional or No Inflation Protection

Optional Inflation provides more inflation protection than No Inflation Protection

• If MetLife’s Policy Inflation Protection is > Existing Policy Inflation Protection,--------then score = +1

• If MetLife’s Policy Inflation Protection is = Existing Policy Inflation Protection,--------then score = 0

• If MetLife’s Policy Inflation Protection is , Existing Policy Inflation Protection,-------------------then score = -1

Complete This Section:

ANNUAL PREMIUM:

Existing Policy $_________________ Replacement Policy $_______________ Difference $_______________

APPLICATION SUBMISSION CHECKLIST

AGENT

Please make sure the following are correct:

Personal Worksheet is completed.If the applicant chooses not to complete the Personal Worksheet, please complete the Authorization to Proceed Processing Application Form.

Only individual applicants complete this application. Multi-Life program group applicants require different applications.

Correct distribution channel is selected in Agent’s Report.

For Automatic Checking Account Deduction of premium, a voided check is included and Part E, Question 3 is completed and signed.

All Health Information is complete.

The Authorization to Release Information to MetLife Form is signed by the applicant(s).

The California Authorization to Release Information is signed by the appli-cant(s), if the applicant(s) want us to provide medical information that isrelevant to our underwriting decision, directly to them.

All signatures boxes are complete.

The Beneficiary Designation Form for the Return of Premium Rider shouldonly be completed if the Applicant is selecting the Return of Premium Riderand chooses to designate a beneficiary other than their estate.

Metropolitan Life Insurance CompanyNew York, NY 10166www.metlife.com

LTC01614(1017) 0505-7946

Documents

Important Notice Regarding MetLife’s Long-Term Care ... · • When Medi-Cal pays your spouse’s nursing home bills, you are allowed to keep your house and furniture, a living